Tenant-Furnished Utilities and Other Services / U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing / OMB Approval No. 2577-0169
(exp. 07/31/2007)
See Public Reporting Statement and Instructions on back
Localityas / Unit Type / Date (mm/dd/yyyy)
Utility or Service / Monthly Dollar Allowances
0 BR / 1 BR / 2 BR / 3 BR / 4 BR / 5 BR
Heatinga. Natural Gas / 19 / 26 / 34 / 42 / 53 / 60
b. Bottle Gas / 49 / 69 / 88 / 108 / 137 / 156
c. Fuel Oil / 31 / 43 / 55 / 67 / 86 / 99
d. Electric / 15 / 21 / 28 / 34 / 43 / 49
Cookinga. Natural Gas / 2 / 2 / 3 / 3 / 4 / 5
b. Bottle Gas / 10 / 13 / 17 / 21 / 27 / 31
c. Electric / 3 / 4 / 5 / 6 / 8 / 9
Other Electric / 9 / 12 / 15 / 19 / 24 / 28
Water Heating a. Natural Gas / 4 / 6 / 7 / 9 / 11 / 13
b. Bottle Gas / 25 / 35 / 45 / 55 / 71 / 81
c. Fuel Oil / 15 / 21 / 28 / 34 / 43 / 49
d. Electric / 9 / 13 / 16 / 20 / 25 / 29
Water / 19 / 27 / 35 / 43 / 54 / 62
Sewer / 21 / 29 / 37 / 45 / 57 / 66
Trash Collection / 15 / 15 / 15 / 15 / 15 / 15
Range/Microwave / 3 / 3 / 3 / 3 / 4 / 4
Refrigerator / 4 / 4 / 4 / 5 / 6 / 6
Other -- specify (Furnace Fan)
Blower / 1 / 2 / 2 / 3 / 4 / 4
Actual Family Allowances To be used by the family to compute allowance. Complete below for the actual unit rented. / Utility or Service / per month cost
Heating / $
Cooking
Name of Family
Other Electric
Air Conditioning
Address of Unit / Water Heating
Water
Sewer
Trash Collection
Range/Microwave
Refrigerator
Number of Bedrooms / Other
Total / $
Previous editions are obsolete / Page 1 of 1 / form HUD-52667 (12/97) ref. Handbook 7420.8